(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Biodiversity Heritage Library | Children's Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "United States Navy Medical News Letter Vol. 34 No. 7, 2 October 1959"

NavMed 369 




j UNITED STATES NAVY j 




ia^!mwtey/«: 



Rear Admiral Bartholomew W. Hogan MC USN 
Captain Donald R. Childs MC USN - Editor 


- Surgeon General 






Vol. 34 Friday, 2 October 1959 




No. 7 



TABLE OF CONTENTS 

Historical Fund of the Navy Medical Department 2 

ABSTRACTS 

Acute Tubular Necrosis 3 

Articular Manifestations of Chronic Ulcerative Colitis 7 

Chemical Therapy of Tumors 9 

Anemia of Rheumatoid Arthritis 12 

Griseofulvin - Oral Antibiotic for Ringworm 13 

Intraosseous Venography 14 

MISCELLANEOUS 

Navy Authority on Space Medicine Retires 15 

From the Note Book . . 16 

Memberships in Civilian Professional Societies (BuMed Inst. 1500. 4B) . . 19 

Appointment in the Medical Service Corps (BuPers Inst. 1120. 15D) 19 

DENTAL SECTION 

Message from Chief of Dental Division 20 

Response to Implants of Anorganic Bone 20 

New Correspondence Extension Course 21 

Newly Standardized Dental Item . 22 

Technician Training in Maxillofacial Prosthesis 22 

RESERVE SECTION 

Tables of Organization (BuPers Inst. 5400. 1H) 23 

Comments We Like to Read 26 

OCCUPATIONAL MEDICINE 

Occupational Health Congress in New York 28 

Radiation as an Industrial Medical Problem 28 

Etiology of Aplastic Anemia 32 

Medical Consideration of Exposure to Microwaves (Radar) 35 



Medical News Letter, Vol. 34, No. 7 



HISTORICAL FUND 

of the 

NAVY MEDICAL DEPARTMENT 



A committee has been formed with representation from the Medical 
Corps, Dental Corps, Medical Service Corps, Nurse Corps, and 
Hospital Corps for the purpose of creating a fund to be used for the 
collection and maintenance of items of historical interest to the Medical 
Department. Such items will include, but will not be limited to, por- 
traits, memorials, etc. , designed to perpetuate the memory of dis- 
tinguished members of the Navy Medical Department, These memorials 
will be displayed in the Bureau of Medicine and Surgery and at the 
National Naval Medical Center. Medical Department officers, active 
and inactive, are invited to make small contributions to the fund. It is 
emphasized that all donations must be on a strictly voluntary basis. 
Funds received will be deposited in a Washington, D. C. bank to the 
credit of the Navy Medical Department Historical Fund, and will be 
expended only as approved by the Committee or its successor and for 
the objectives stated. 

It is anticipated that an historical committee will be organized at each 
of our medical activities. If you desire to contribute, please do so 
through your local historical committee or send your check direct, 
payable to Navy Medical Department Historical Fund, and mail to: 

Treasurer, N. M. D. Historical Fund 
Bureau of Medicine and Surgery (Code 14) 
Department of the Navy 
Washington 25,- D. C. 



Committee 

F. P. GILMORE, Rear Admiral (MC) USN, Chairman 
C. W. SCHANTZ, Rear Admiral (DC) USN 
L. J. ELSASSER, Captain (MSC) USN 
R. A. HOUGHTON, Captain (NC) USN 
T. J. HICKEY, Secretary-Treasurer 



Medical News Letter, Vol. 34, No. 7 



Acute Tubular Necrosis 



The mortality rate from acute tubular necrosis should be low because: 
(1) the damaged renal tubule is able to undergo relatively complete regenera- 
tion; (2) physiologic principles have been applied to minimize fluid and electro- 
lyte alterations which accompany acute renal failure; and (3) there has been 
almost universal acceptance of hemodialysis as a procedure capable of im- 
proving many of the biochemical abnormalities and symptoms attributable to 
them. However, despite reports that would indicate achievement of the 
objective, discouraging results are being obtained at renal centers with the 
most experience and equipment. The mortality rate of the authors' series 
of 100 cases of acute tubular necrosis was 50%. 

Results of the present study indicate that prognosis is related both 
to the nature of the injury leading to renal damage and to ensuing complica- 
tions. Improved survival rate requires further efforts directed toward the 
understanding and prevention of complications. 

Analysis of the cases according to etiologic background reveals 
significant differences in mortality rates. The cases were divided according 
to common factors in development of tubular necrosis: (1) surgery, (2) trauma, 
(3) transufsion hemolysis, (4) obstetrical complications, (5) exposure to nephro- 
toxic agents, and (6) unknown or miscellaneous factors. 

In the majority of patients who developed oliguria after a surgical pro- 
cedure there was a significant fall in blood pressure of varying duration, but 
oliguria continued after restoration of blood pressure to normal. In 4 patients 
there was no fall in peripheral blood pressure; nevertheless, the pathogenesis 
of renal failure was probably the same — a marked reduction in renal blood 
flow without an accompanying peripheral vascular collapse. 

Of 32 cases in this group, there were 23 fatalities (72%) with deaths 
due to complications arising after onset of renal failure. 

The group receiving trauma and then developing tubular necrosis con- 
sisted of 6 patients, 5 of whom died of their disease combination. The renal 
lesion was thought to be directly responsible for death in 2 patients. 

Twenty-four patients were included in the group suffering transfusion 
hemolysis. The mortality rate was 29% with 6 of the 7 fatalities resulting 
from transfusions that were not unequivocally indicated. There was no cor- 
relation between the amount of incompatible blood given and severity of 
renal damage. 

Sixteen patients developed acute renal failure as a result of obstetri- 
cal complications, and death of 4 resulted. 

Tubular necrosis developed in 9 patients who were exposed to neph- 
rotoxic substances — carbon tetrachloride and bichloride of mercury. There 
were 5 deaths with 3 of them being attributable to the toxic agent. 

Thirteen patients were included in the category of renal damage 
resulting from miscellaneous factors, such as the procedure involved in 



Medical News Letter, Vol. 34, No. 7 



performing an aortogram, nontraumatic rupture of the spleen, severe infec- 
tions, and dehydrations. The mortality rate in this group was 46%. 

Reasons for differences in mortality are not clear. While the extent 
and distribution of the tubular lesions are known to vary according to etiologic 
background, this is of doubtful clinical significance. Such factors as dis- 
ease in other organs, presence of devitalized tissue, increased portals of 
entry for infection, and accelerated catabolic response are equally as im- 
portant as the extent of renal damage in determining outcome of any case. 
These complicating factors and their effect upon the metabolism of urea, 
potassium, and phosphorus have been stressed by many writers. 

Age and sex appear to have no relationship to survival, while duration 
of oliguria has an inverse relationship. Of all fatalities, 42% occurred during 
the diuretic period, even after the restoration of a normal BUN and achieve- 
ment of peak urinary volume. As would be expected, pre-existing renal 
disease contributes to a prolonged and more complicated course. 

All patients developed the symptom complex of "uremia" to a greater 
or lesser degree. Certain specific complications were considered to be of 
particular importance in management and prognosis of these patients. 

Infection was the most frequent complication observed. Some evi- 
dence of infection was manifested by 80% during the course of disease. In 
2 7 the infection was minor, such as cystitis or superficial wound abscess; 
in 53 it was of consequence, consisting of one or more of such entities as 
pneumonia, tracheobronchitis, septicemia, peritonitis, deciduitis, or parotitis. 
Infection played a major part in 72% of all deaths. 

The highest incidence of major infection occurred in the surgical and 
miscellaneous groups; the lowest in the hemolytic transfusion and nephro- 
toxic groups, suggesting some correlation between incidence of infection and 
degree of initial tissue damage. 

Unfortunately, not only does the acutely uremic patient appear more 
susceptible to bacterial invasion, but the infectious process is extremely 
difficult to control. Response to antibiotics is generally poorer than that of 
the nonuremic patient. The few studies which have been attempted to assess 
the influence of renal failure on natural defense mechanisms against bacteria 
have failed to show impairment of antibody response, complement production, 
or leukocyte phagocytosis. 

Five patients died from potassium intoxication although the incidence 
of hyperkalemia (41%) was much higher. The rate of rise of the serum 
potassium bears important implications not only with regard to the potential 
danger of cardiac arrest, but also as a reflection of the catabolic response 
of the patient. 

Cardiopulmonary complications other than those of infection devel- 
oped in 49% of patients E^nd were primarily responsible for death in 12. These 
included cardiac arrhythmias, congestive heart failure, and a peculiar syn- 
drome resembling pulmonary embolism clinically but not pathologically. 



Medical News Letter, Vol. 34, No. 7 



Coma and convulsions are the two most important disturbances of the 
central nervous system that accompany acute tubular necrosis. Their impor- 
tance as being a cause of death is difficult to assess. Incidental results of 
coma are more serious than the condition itself. Pneumonia, decubitus 
ulcers, aspiration of vomitus, tracheal obstruction, and urinary retention 
are all conditions which may develop and are of serious import in regard to 
prognosis. 

Attempts to define the biochemical disturbances responsible for cen- 
tral nervous system depression have not been successful, although such 
compounds as phenols and guanidine have been implicated at one time or 
anothe r . 

Generalized convulsions occurred in 27 patients. The greatest danger 
from this complication is the associated anoxia with accentuation of an already 
threatening hyperkalemia. The etiologic factor of this phenomenon also is 
obscure. 

Bleeding tencency is recognized as a common complication of both 
acute and chronic uremia. In this series, 49% of patients bled at some time 
during their illness exclusive of the period during or immediately following 
dialysis. From study of coagulation factors in instances of bleeding in these 
cases, it is suggested that other factors, such as capillary fragility, may 
play a major role, as coagulation defects in themselves do not appear to be 
statistically different in the bleeding and nonbleeding groups. 

Tissue repair is defective in patients with uremia, resulting in delay 
in wound healing which contributes to the development of infection, depletion 
of labile protein stores, and possibly the biochemical abnormalities of uremia. 

Although it is not the purpose of this report to detail the management 
of acute renal failure, several points with respect to prevention and treat- 
ment of complications need to be emphasized. 

The greatest salvage of life in patients with acute tubular necrosis 
will stem from prophylaxis against infection. This requires constant sur- 
veillance and careful attention to details of good medical and nursing care. 
Attention to the respiratory tract is one of the most important facets of 
management, and maintenance of meticulous oral hygiene is mandatory. Phys- 
ical activity — within the patient's tolerance — during the acute stage of the 
disease and as early in convalescence as is practicable, is desirable. Cath- 
eterization of the urinary bladder is to be avoided — the only absolute indica- 
tion being lower urinary tract obstruction. Infection must be treated boldly 
with specific agents. 

Temporary measures — intravenous hypertonic glucose with insulin, 
calcium gluconate, and sodium lactate — may be used when indicated for 
reduction of serum potassium level. Longer lasting effects may result from 
oral or rectal administration of cation exchange resins which remove potas- 
sium from the body, although dialysis remains the most efficient method for 
removal of potassium. 



Medical News Letter, Vol, 34, No. 7 



Recognition of the necessity for fluid restriction in these patients will 
lead to decreased incidence of congestive heart failure. Under average con- 
ditions normal hydration in the adult patient can be maintained by daily ad- 
ministration of approximately 600 ml. of fluid in addition to measured loss. 
When extrarenal losses are excessive, daily weights provide a more reliable 
index of fluid balance. Digitalis must be employed with caution and careful 
clinical observation. 

Therapeutic attempts to improve blood coagulation and control bleeding 
tendencies are disappointing. Platelet transfusions, thromboplastic substances, 
and fresh-frozen plasma are theoretically indicated but notably ineffective. 
Judicious surgical intervention at times may pay dividends. 

At present, the therapy of delayed wound healing consists mostly of 
local measures. 

In the series reported, extracorporeal hemodialysis was performed 
69 times on 52 patients. The fact that the mortality rate of dialyzed patients 
was identical with that of other patients (50% in each instance) has no real 
significance as the two groups were not comparable considering the severity 
of illness. Unequivocal evidence that dialysis will reduce the mortality rate 
in this disease must await analysis of larger, well-controlled series of 
patients with common etiologic background. It seems reasonable to believe 
that if dialysis is performed relatively early in the course of uremia, clin- 
ical deterioration may be prevented or delayed sufficiently to avoid some of 
the serious complications discussed in this paper. Consequently, the authors 
are inclined to agree with others that dialysis will be most effective when 
carried out earlier and more frequently than has been customary in the past. 
(Bluemle, L. W. Jr. , Webster, G. D.Jr., Elkinton, J.R. , Acute Tubular 
Necrosis - Analysis of One Hundred Cases with Respect to Mortality, Com- 
plications, and Treatment with and without Dialysis: A. M. A. Arch. Int. Med., 
104 : 180-195, August 1959) 

i|« %f & if Of a£ 

Policy 

The U.S. Navy Medical News Letter, is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be, 
nor are they, susceptible to use by any officer as a substitute for any item 
or article in its original form. All readers of the News Letter are urged 
to obtain the original of those items of particular interest to the individual. 



Medical News Letter, Vol. 34, No. 7 



Articular Manifestations of Chronic Ulcerative Colitis 

The belief appears to be well established that arthritis is an occas- 
ional complication of chronic ulcerative colitis, that its presence is an ad- 
ditional indication for surgical management of colitis, and that removal 
of the diseased colon results in remission of arthritic symptoms. The 
literature is vague, however, regarding the type of arthritis involved and 
its rate of occurrence. 

The author studied the records of 555 patients with chronic ulcera- 
tive colitis seen at the Lahey Clinic from 1926 through 1955 in an attempt 
to classify articular manifestations of chronic ulcerative colitis, to estimate 
their frequency in a large group of patients, and to correlate them to the 
activity of colitis. 

Of the patients with chronic ulcerative colitis in this study, 290 
(52. 3%) were women; no sex differential was found regarding age at onset; 
in 80% the disease began in the second, third, or fourth decades; articular 
manifestations occurred in 95 patients (17%) of whom 54 were women; 
of the entire group, 335 {60. 3%) underwent colectomy and ileostomy. 

Rheumatoid arthritis occurred in 18 patients (3.2%) of whom 11 were 
women. The joint disease developed a year or more after onset of colitis in 
14, and activity of the arthritis closely paralleled the ebb and flow of colitis 
in 8 patients. In the remaining 10 patients the two diseases apparently fol- 
lowed independent courses. Eleven patients in this group underwent colec- 
tomy and ileostomy, but in 10 the arthritis continued unabated postopera- 
tively. 

Rheumatoid spondylitis was present in 28 patients (5%), 20 of the 
group being males. In only 4 patients was there any correlation between 
spondylitic manifestations and activity of the colitis, and only 3 of the 15 
patients receiving surgery showed any abatement of symptoms following 
surgery. 

Peripheral joint arthralgias were present in 23 cases (4.2%). In 20 
cases arthralgias paralleled the course of the colitis, and only one patient 
out of 15 receiving surgery failed to show relief of symptoms. 

Lesions of erythema nodosum occurred in 16 patients (2. 8%). In 
every case associated arthralgia or acute arthritis was present — usually 
of knees or ankles, or both. In 14 patients erythema nodosum paralleled 
the activity of colitis, and colectomy and ileostomy were successful in all 
cases (9 patients) in preventing recurrence of the lesions. 

A group of 10 patients (1.8%) presented articular manifestations that 
could not be included in the previous categories. Swollen joints were pres- 
ent in all, but three features distinguished them from the others. (1) Articu- 
lar swelling occurred simultaneously with the first attack of colitis in 6 
patients and with subsequent attacks in 3. (2) In all cases articular manifes- 
tations were completely absent during periods of quiescence of the colitis 



8 Medical News Letter, Vol. 34, No. 7 



and following colectomy and ileostomy — which all received — none of the 
patients suffered recurrence of articular manifestations. (3) In this group 
only large joints were involved. 

English and American literature contains few references to the arti- 
cular manifestations of chronic ulcerative colitis, and then only as "arthritis" 
or "arthralgias. " Only recently has an attempt been made to define criteria 
for the diagnosis of rheumatoid arthritis. The application of current nomen- 
clature cannot be precisely applied to this study, but it is clear that the fore- 
going are five types of articular manifestations of chronic ulcerative colitis. 

The frequency of articular manifestations in chronic ulcerative colitis 
has been stated to vary from 4 to 20%. Strict comparison of the present study 
with previous ones is not possible because of the ambiguity in terminology 
that has existed. The prevaleneeof articular manifestations reported by the 
author was 17%. 

In the present study, rheumatoid spondylitis was the most frequent 
articular manifestation which was a surprising observation because only 
recent mention of this relationship has appeared in the literature of the 
English language. The ratio of men to women in the present series was less 
than 3: 1 — a much lower ratio than is usually associated with rheumatoid 
spondylitis. These findings suggest that this form of arthritis should be care- 
fully looked for in all cases of chronic ulcerative colitis associated with back 
pain or peripheral joint symptoms. 

The frequency of the other joint manifestations of this series showed 
no great variation from frequency rates reported by other observers. 

In evaluating the relationship between the clinical course of joint 
manifestations and disease of the colon the author concludes that there is no 
close association between the course of rheumatoid spondylitis and chronic 
ulcerative colitis, and that rheumatoid spondylitis per se is not an indication 
for colectomy since its remission after this procedure is most unlikely. Arth- 
ralgias were closely related to colitis in this series, and colectomy resulted 
in total disappearance of the arthralgias in almost every case. However, 
since they are not in themselves severe or crippling forms of disease, their 
presence alone is not an indication for colectomy in cases of chronic ulcera- 
tive colitis. 

A positive correlation is made between the course of rheumatoid 
arthritis and colitis in 44%, although with one exception, colectomy did not 
result in remission. Therefore, the concurrent presence of rheumatoid arth- 
ritis is not an indication for colectomy. 

Erythema nodosum appears to be closely related to the activity of the 
colitis, and in this series remission always followed colectomy. However, 
unless the erythema nodosum is particularly severe its occurrence should not 
constitute an indication for colectomy. 

"Acute toxic arthritis" presents a close relation to the activity of colitis, 
with colectomy seemingly effecting a cure. Under these circumstances, surg- 
ery would seem to be indicated. 



Medical News Letter, Vol. 34, No. 7 



The question of whether the articular manifestations of chronic ulcer- 
ative colitis are secondary to the colitis, unrelated, or part of the same 
disease can be answered only when a clearer understanding of the etiology 
and epidemiology of arthritides in general and chronic ulcerative colitis is 
established. Some observers believe that histologically synovial lesions 
in chronic ulcerative colitis are indistinguishable from those of rheuma- 
toid arthritis. At this time, not enough is known about the significance of 
serologic tests to base a classification on their results. In the present 
series, latex-fixation tests generally gave positive results in the patients 
who had colitis and rheumatoid arthritis, and negative results in those. with 
colitis and spondylitis or arthralgias. This result is in general agreement 
with findings in the cases of uncomplicated arthritides. 

An interesting view has been expressed by Grey who wonders whether 
chronic ulcerative colitis might not belong to the family of "collagen" dis- 
eases. Others have made much the same conjecture. On the basis of the 
present study, the author agrees with Bargen who stated that "whether or 
not the arthritis should be called a complication or an associated disease 
is a debatable question. " (Fernandez-Herlihy, L. , The Articular Mani- 
festations of Chronic Ulcerative Colitis - An Analysis of 555 Cases: New 
England J. Med., 26_1: 259-263, August 6, 1959) 

•Jj- Jr Jj» -ill- -.',- -JU 

*T" *t~ *T" <i» ■'p *f" 

Chemical Therapy of Tumors 

Although chemical agents capable of curing human cancer are not yet 
available, significant achievement in suppressive chemotherapy has been 
made. 

A number of general approaches have been employed in the develop- 
ment of agents for use in cancer chemotherapy. If a metabolic pathway can 
be found that is sufficiently unusual for tumor cells, it should be possible 
to fashion an appropriate inhibitor of the pathway. 

The classes of drugs currently used in cancer chemotherapy include 
hormones, antibiotics, alkylating agents, and antimetabolites. 

The demonstration by Huggins of the effectiveness of di ethyl stilbe sterol 
in prostatic carcinoma was the first evidence that a synthetic compound of 
known chemical structure could influence the growth of a human neoplasm. 
Agents of this sort are effective in inducing regressions in tumors which 
are hormone dependent; thus, their effectiveness is limited to a few tissues 
and to a few tumors of those tissues. 

The use of cortisone, related steroids, or cortocotrophin in the treat- 
ment of the acute leukemias of childhood would appear to be an example of 
another principle of hormone therapy in cancer, but the mechanism of 
suppression of leukemic cells or normal lymphocytes by these steroids is 



10 Medical News Letter, Vol. 34, No. 7 



unknown. Relatively shorter remission is experienced with this agent than 
with other chemotherapeutic agents, although a more prompt response is 
obtained. Therefore, combined therapy is employed. 

Bacterial toxins were among the earliest agents said to be of use in 
the chemotherapy of cancer and the effectiveness of antibacterial antibiotics 
has served to focus attention on the study of antibiotics as inhibitors of tumor 
growth. Temporary regression has been observed in some human tumors 
following treatment with Actinomycin D. Another antibiotic derived from 
streptomyces, Mitomycin C, has been reported to have induced tumor re- 
gression in patients treated in Japan. 

The agents most generally useful in the chemotherapy of cancer in 
experimental animals as well as in man are the alkylating agents and the 
antimetabolites. The antitumor effects of these compounds have been cor- 
related with effects on the biosynthesis of the nucleic acid purines. The 
development of folic acid antagonists represented the first useful application 
of the antimetabolite principle to cancer chemotherapy. 

In children with acute leukemia, clinical and hematologic evidence of 
remission has been reported in 20 to 70% of patients after 3 to 8 weeks of 
treatment with folic acid antagonists. Complete remission has been observed 
in Z0 to 30% of children treated. Amethopterin is the folic acid antagonist 
in most general current use. 

The literature reported that the 50% survival time in children with 
untreated leukemia was 4 months. This figure was doubled following the 
advent of the folic acid antagonists and steroid hormones. The percentage 
of patients surviving longer than one year was 5% prior to the development of 
these two forms of therapy and 24% thereafter. Recently, folic acid antagon- 
ists have been reported to induce remissions in certain cases of lymphosar- 
coma in childhood. 

The synthesis of 6-mercaptopurine represented part of a continuing 
study of purine metabolism and its inhibition as an approach to cancer therapy. 
The mechanism of action is not known, but incorporation into nucleic acids 
of viscera of mice and leukemic cells in man has been observed. Clinical 
and hematologic remissions have been achieved in approximately 50% of 
pediatric patients treated with this agent alone, and the percentage of patients 
surviving longer than one year has been increased to 52%. 

The most recent addition to the list of antimetabolites of interest in 
cancer chemotherapy resulted from the synthesis of 5-fluorouracil and 5-flu- 
oroorotic acid. The details of their utilization in the formation of nucleic 
acids have not been defined. Clinical trials have been reported and striking 
regressions have been observed in some solid tumors. Serious undesirable 
effects have been observed and attempts are in progress to alter the biologic 
properties of the compounds. 

The other general class of compounds useful in cancer chemotherapy 
is that of the alkylating agents. Experience during World War I revealed 



Medical News Letter, Vol. 34, No. 7 11 



profound toxic effect on lymphoid tissue of nitrogen mustards. Experiments 
with these agents constituted the first demonstration that it was^possible for 
a synthetic compound to induce regression in human tumors arising from 
tissues not under endocrine control. Only a few tumors or types of tumors 
are affected by this agent and the therapeutic index is low. These considera- 
tions have led to a search for similar agents which might possess greater 
activity and lower toxicity or selectivity of penetration. 

Search for chemotherapeutic agents among derivatives of ethylenimine 
was suggested by the fact that the initial reaction of the aliphatic nitrogen 
mustards in water is the loss of chloride with the formation of cyclic ethyl - 
enimonium ion. Among the first of these compounds to be employed in cancer 
chemotherapy was triethylene melamine (TEM). A large series of similar 
compounds has been formed, with the principal advantage that they may be 
given orally. Variations of the chemical formula have resulted in Myleran — 
toxic to granulocytes — which has been used effectively in the treatment of 
chronic granulocytic leukemia; and Chlorambucil and Leuke ran —-toxic to cir- 
culating lymphocytes — effective against chronic lymphatic leukemia. 

One of the more recent developments in the area of antimetabolites 
and alkylating agents has been the synthesis of compounds designed to be at 
the same time alkylating agents and structural analogues of important inter- 
mediate products of cellular metabolism. In these compounds the intermed- 
iate substance might serve as a carrier for the cytotoxic agent, providing 
some selectivity of entry into particular areas of certain cells. Observations 
indicate that amino acids might be appropriate carrier structures, and the 
possibility is suggested that greater specificity of antitumor action might be 
achieved by the preparation of cytotoxic derivatives of molecules such as 
peptides or proteins. 

The synthesis of alanine and phenylalanine mustards represented the 
first example of the deliberate addition of a cytotoxic alkylating group to an 
amino acid residue. Reports from a number of laboratories provide encourage- 
ment that a new avenue of therapy may be opening up. Added to a growing 
group of the amino acid mustards is Aminochlorambucil with increased toxicity 
for lymphocytes; a nitrogen mustard derivative of serine with an improved 
therapeutic index and low toxicity; mustard derivatives of sugars developed 
in Hungary; and benzimidazole and pyrimidine combinations. An interesting 
and potentially valuable asset of sugar compounds is their ability to prevent 
development of metastatic implants. Experiments suggest the use of this 
agent to prevent metastatic spread at operations. 

Although chemotherapeutic inroads into the problem of human neo- 
plastic disease have as yet been small, these observations should serve as 
a stimulus for further definition of the metabolism of neoplastic cells and of 
the mechanisms by which available agents exert their cytotoxic effects. 
(Nyhan, W. L. , Approaches to the Chemical Therapy of Tumors: J. Pediat. , 
55: 337-354, September 1959) 



12 Medical News Letter, Vol. 34, No. 7 



Anemia of Rheumatoid Arthritis 

The anemia of rheumatoid arthritis has attracted the attention of 
investigators for many years, but its pathogenesis has remained elusive. 
All studies indicate that anemia is a frequent finding, reflecting the clinical 
activity of the disease. Disturbances in iron metabolism have also been 
noted. In all other respects the reported data are in marked disagreement. 
In earlier work on this problem the importance of erythrocyte suppression as 
the basic mechanism in the pathogenesis of this anemia was usually stressed. 
These conclusions were reached chiefly on the basis of evaluation of the 
appearance of the bone marrow aspirate. However, in a recent study, the 
utilization of intravenously injected tracer doses of iron for hemoglobin syn- 
thesis was normal. Evidence for overt hemolysis in the anemia associated 
with rheumatoid arthritis has been contradictory and not impressive. 

The most marked area of disagreement is in regard to the cause and 
relative importance of the disturbances in iron metabolism. Like most 
anemias associated with inflammation, the anemia of rheumatoid arthritis 
is often hypochromic. Similarly, there is a moderate reduction in the serum 
iron level, but often the reported effects of iron therapy have not been consis- 
tent. Recently it has been suggested that the disturbances in iron metabolism 
may be the result of failure to mobilize iron from the reticuloendothelial cells. 

Making detailed studies on 18 patients with rheumatoid arthritis and 
comparing results with a series of control patients, the author's findings 
confirm the common observation that the anemia of rheumatoid arthritis re- 
flects the activity of the disease, and that moderate degrees of hypoferremia 
are noted in most of the cases. A slight degree of hypochromia was noted in 
the peripheral blood smear of these patients. However, calculation of the 
mean corpuscular hemoglobin concentration revealed no significant deviation 
from the normal. The patients of this series had normal to low iron-binding 
capacities, normal absorption of iron from the gastrointestinal tract, and 
ample to increased iron stores in the bone marrow — all observations indicat- 
ing that the anemia was not that of iron deficiency in the usual sense. Fur- 
thermore, parenteral iron appeared to be of no benefit. 

Increased plasma volumes were found in some cases, although for 
various reasons the author did not consider the observations totally valid 
and was unable to explain the phenomenon. Shortening of red cell survival 
and abnormalities in iron metabolism were noted and were considered sig- 
nificant in the pathogenesis of the anemia, the former indicating a process 
of hype rhemoly sis. Patients with atypical rheumatoid arthritis tended to 
have a greater degree of red cell destruction than those patients with a more 
classic form of the disease — particularly those with splenomegaly. The 
magnitude of increased red cell destruction in itself was not considered to 
be responsible for any developed anemia, possibly indicating some inappro- 
priate bone marrow response or a defect in the availability of iron from 



Medical News Letter, Vol. 34, No. 7 13 



the senescent red cells and defect in mobilization of iron from the reticuloendo- 
thelial cells. In the patients studied, intravenous radioiron was employed for 
erythrocyte production in a normal manner. 

Although the occurrence of anemia with rheumatoid arthritis is a well 
established fact, the author suspects the possibility of complications when the 
degree of anemia is severe. These include superimposed iron deficiency due 
to blood loss, the development of the malignant phase of rheumatoid arthritis, 
the presence of congestive splenomegaly, or the presence of underlying dis- 
seminated lupus erythematosus rather than rheumatoid arthritis. (Weinstein, 
I, M. , A Correlative Study of the Erythrokinetics and Disturbances in Iron 
Metabolism Associated with the Anemia of Rheumatoid Arthritis: Blood, XIV : 
950-964, August 1959) 

'!= * * =!= * * 
Griseofulvin - an Oral Antibiotic for Ringworm 

Superficial fungous infections have plagued man, animals, and plants 
since the dawn of time. Treatment has been partially effective against infec- 
tion of the glabrous skin, largely ineffective against infection of the hair, and 
completely ineffective against infection of the nails. 

The first significant advance in the direction of a specific systemic 
avenue of therapy was the discovery of nystatin, an antibiotic obtained from 
Streptomyces noursei, which was effective against yeast-like fungi {e.g. , 
monilia) but not against the common dermatomycoses. The break-through in 
therapy was the discovery of griseofulvin, derived from several penicillia. 
To date, a limited number of reports are available in medical literature, but 
results tend to be encouraging. 

Current consensus is that griseofulvin is a remarkably effective remedy 
for the common dermatomycoses which include those caused by the Microsporon, 
Trichophyton, and Epidermophyton varieties of fungi. It is not effective against 
tinea versicolor, candidiasis, moniliasis, thrush, or the deep fungous infec- 
tions — blastomycosis, sporotrichosis, coccidioidomycosis, actinomycosis, 
histoplasmosis, et cetera. 

Toxic reactions to administration were few and minor in nature. Some 
patients experienced headache or gastrointestinal distress during the first few 
days, but usually subsided on continued administration. An occasional patient 
developed an urticarial eruption which required discontinuation of the drug. 
Hematologic and visceral function tests showed no abnormalities attributable 
to griseofulvin. An interesting incidental observation was that some of the 
author's patients with a history of reactions to penicillin suffered no adverse 
reactions to penicillium- derived griseofulvin. 

The usual adult dose is 1 gm. per day taken orally in 4 equal doses. 
Itching of cutaneous ringworm lesions ceases within 3 to 5 days, followed by 



14 Medical News Letter, Vol. 34, No. 7 



desquamanation and a temporary brownish discoloration, with clearing in 
about 3 weeks — longer with involvement of scalp ahd thicker layers of skin. 
New nail growth occurs at the nail root in 2 to 4 weeks, but treatment is 
continued until the entire nail-plate has grown out, requiring 4 to 6 months. 

It is emphasized that griseofulvin is fungistatic, not fungicidal, and 
that treatment must be continued until the affected parts are both clinically 
and mycologically negative. 

Intelligent use of griseofulvin is dependent upon a basic knowledge of 
both dermatology and mycology. All that is ringed is not ringworm, and all 
ringworm need not be ringed. Similarly, all scalp affections and nail dis- 
tortions are not of fungal etiology. 

Inevitably griseofulvin will be wrongly condemned as useless when 
used in dermatoses which are not due to fungous infection. The high cost 
of antibiotic medication should be a deterrent to casual and indiscriminate 
prescribing unless the diagnosis is certain. {Weiner, M. A. , Gant, J.Q. Jr. , 
Griseofulvin - an Oral Antibiotic for Ringworm of the Skin, Hair, and Nails. 
A Preliminary Report: Med. Ann. , District of Columbia, XXVIII : 423-425, 
August 1959) 



Intraosseous Venography 

Studies on portal hypertension have been focused upon anatomy, path- 
ology, and altered hemodynamics of the portal venous bed. Newer radio- 
logic and physiologic techniques have significantly advanced knowedge of the 
basic mechanisms involved in this condition. 

From their experience with costal intraosseous venography, the 
authors present data and observations on the systemic venous collateral cir- 
culation in portal hypertension. This method consists of injecting contrast 
material directly into the medullary cavity of a rib. 

Previous work has shown that such technique demonstrates venous 
pathways not outlined by conventional means. When radio -opaque material 
is injected into the marrow of a rib a fairly constant intrathoracic vascular 
pattern can be outlined in the normal subject. As a sequel, certain disease 
states are observed to produce rather constant alterations of the normal 
venous pattern. 

Experience of the senior author with over 1, 000 injections into a 
variety of bones including over 500 ribs resulted in the conclusion that the 
procedure is free of immediate or late ill effects if specified precautions 
are observed. 

The venous pattern in patients with portal hypertension is distinctly 
different from that observed in the normal subject. A complicated and seem- 
ingly confusing network of venous channels may replace the normal simple 



Medical News Letter, Vol, 34, No. 7 15 



co*.iiguration. Abnormal systemic venous forms maybe present even though 
esophageal varices are not demonstrable on esophagograms or by esophagos- 
copy. Various alterations in the systemic venous patterns are illustrated 
and tabulated. 

The authors contend that the systemic venous pattern in portal hyper- 
tension is distinctly different from the ones produced by other intrathoracic 
disorders, such as by a superior vena cava syndrome or cardiac decompensa- 
tion. 

Costal intraosseous venography may prove to be a valuable tool in the 
evaluation of equivocal diagnostic problems with hepatomegaly and/or splen- 
omegaly, and with acute upper gastrointestinal tract hemorrhage of obscure 
origin. The existence of portal hypertension would be improbable in the 
presence of a normal intrathoracic systemic venous pattern. Conversely, the 
roentgenographic demonstration of altered systemic venous hemodynamics, 
a,s observed in portal hypertension, would invite further diagnostic procedures 
in an effort to clarify the degree and type of hemodynamic alterations within 
the portal venous jed. (Schobinger, R. , Cooper, P., Rousselot, L.M., 
Observations on the Systemic Venous Collateral Circulation in Portal Hyper- 
tension and Other Morbid States Within the Thorax: Ann. Surg. , 150: 188- 
195, August 1959} 

sjc >)c s}t # $ $ 

Navy Authority on q pace Medicine Retires 

CAPT Norman L. Barr MC USN, one of the Navy's leading authorities 
on space medicine and, until recently, Director of the Astronautical Division, 
Bureau of Medicine and Surgery, was placed on the retired list 1 September 
1959, closing a 21-year naval career. Prior to his commission in the Navy, 
CAPT Barr served in the U.S. Army Reserve for three years and spent over 
9 years in the U.S. Army Air Force. 

Born in Myrtlewood, Ala. , in 1905, CAPT Barr studied medicine at 
Georgetown University Medical School, Washington, D. C. , receiving his 
M. D. degree in 1937. He was appointed LTJG in the Medical Corps of the 
Navy on 16 July 1938; was designated naval flight surgeon in 1940; and 
through subsequent promotions attained the rank of captain in July 1954. 

From 1943 to 1946 CAPT Barr servedas medical officer, flight 
surgeon, and naval aviator on board various aircraft carriers and fleet 
activities. In 1946 he was assigned in the Bureau of Medicine and Surgery 
as Officer-in-Charge of Special Activities and Director of Project RAM 
(Research Aviation Medicine), a joint project of the Bureau of Medicine and 
Surgery and the Bureau of Aeronautics. In this assignment he was concernei 
with establishment of the Naval Acceleration Laboratory, Johnsville, Pa. , 
the Space Orientation Laboratory, Pensacola, Fla. , and research programs 



16 Medical News Letter, Vol. 34, No. 7 



in high altitude physiology and bio-physics. In 1950 he was assigned as Head, 
Aviation Medicine Division, Naval Medical Research Institute, Bethesda, Md. 
In 1956 he returned to the Bureau of Medicine and Surgery where he served 
as Deputy Director, Research Division, and later as Director, Astronautical 
Division. 

CAPT Barr has compiled more than 12, 000 hours in the air of which 
more than 8, 000 have been as first pilot. He is the only known officer in the 
military service who is entitled to wear five separate Military Aviation Wings: 
Air Force Pilot, Air Force Observer, Air Force Flight Surgeon, Navy Flight 
Surgeon, and Naval Aviator. 

Many of the accomplishments of the Navy's medical research program 
were developed during the time of CAPT Barr's association with them. While 
directing project RAM he developed a system which gathers physiologic infor- 
mation from pilots in the air as well as from animal and human occupants of 
earth-orbiting vehicles, transmits the information to the ground by radio, 
relays it to a central laboratory by radio and telephone from any part of the 
world, and records it automatically. In the present state of perfection, the 
equipment permits transmission of electrocardiogram, electroencephalogram, 
body temperature, skin temperature, respiratory rate, respiratory volume, 
and other physiologic determinations, 

CAPT Barr is the author of many medical and scientific professional 
papers. He is a Fellow, Aero-Medical Association; member, Space Medicine 
Association; member, Association of Military Surgeons; Fellow, American 
College of Cardiology; Diplomate, American Board of Preventive Medicine 
in Aviation Medicine; and member, Alpha Omega Alpha medical honor society. 

(TIO, BuMed) 

£ >'f. :Jc Hf 4* 9$ 

From the Note Book 

Foreign Officers Receive Navy Training . Twenty-three medical, dental 
and nurse military officers representing eleven allied countries, began post- 
graduate training at the U. S. Naval Medical School, National Naval Medical 
Center, Bethesda, Md. , on 3 September 1959. The program, part of President 
Eisenhower's People-to-People Programandthe Military Assistance Program 
of the Navy, includes Naval Medical Management, Dental Management, Prev- 
entive Medicine, and Orientation for Military Nurses. (News Release, NNMC) 

U.S.N. Hospital Invitation. In a recent letter addressed to the Surgeon 
General, CAPT L. E. Bach MC USN, Commanding Officer, U.S. Naval 
Hospital, Camp Lejeune, N. C. , stated: "We are making an effort to get all 
(Medical Department Personnel) attached to other commands to feel at home 
in our hospital and to feel that we are all on the same team. Last week I had 



Medical News Letter, Vol. 34, No. 7 17 



the first meeting and luncheon with all the senior Medical officers of other 
activities at Camp Lejeune, Everyone expressed pleasure at being able to 
attend and a desire that such meetings continue. They will be held at monthly 
intervals. I believe these meetings will be a great help in solving mutual 
problems as well as providing an opportunity to meet occasionally with some 
very fine colleagues. " 

Exhibition Cited. The Hospital Administration Division of the Bureau of 
Medicine and Surgery participated in the presentation of a Federal Hospital 
Exhibit at the recent American Hospital Association meeting in New York City. 
This exhibit, one of 50 education exhibits, was selected as the best of its clas- 
sification. The panel from the Bureau, which dealt with Work Simplification 
applied particularly to linen procedures, was well received. (TIO, BuMed) 

Cows, Horses — and Krebiozen . From the Executive Director's News Letter 
of the September GP comes this terse book review: "Herbert Bailey's book, 
'A Matter of Life or Death, ' is another impassioned plea for Krebiozen. . . . 
Bailey . . . unwittingly uses himself to show how an uninformed layman can 
be euchred into blind allegiance by not knowing how to tell facts from fiction. 
. . . According to Bailey, the answer came to Dr. Steven Durovic as 'the 
fair rich fields of his family's ancestral estate rolled before his mind's eye 
and he saw again the family herds of cows and horses. What else is there 
to say?" 

Sports Injuries . The September issue of the American Journal of Surgery is 
devoted to an extensive symposium on Sports Injuries with 26 articles cover- 
ing the topic from Physical Fitness for Sports, Athletics and Nutrition, and 
The Place of the Trainer in Modern Athletics, to a series of discussions of 
management of injuries of specific anatomical regions. 

Bleeding Duodenal Ulcer . From a study of 162 consecutive cases of bleeding 
duodenal ulcer at U.S. Naval Hospital, Philadelphia, the authors conclude 
that greater stress should be placed on pain patterns. The "silent bleeder" 
would be the patient demanding more vigorous therapeutic measures. Various 
other factors in relationship to bleeding were detailed and discussed. 
(LT Jay Desjardins MC USN, et al. , J. A.M. A. , 29 August 1959) 

Pituitary Tumor . Twelve of a series of 122 patients with adrenal hyperplasia 
and Cushing's syndrome studied at the Mayo Clinic had clinical or histologic 
evidence of pituitary tumor. Six of the 12 patients had ocular abnormalities. 
The incongruous homonymous nature of the field defects and the involvement 
of the third nerve indicated parasellar extension of the tumor. From these 
observations it appears that roentgenographic study of the sella, ophthalmo- 
scopic examination, and plotting of visual fields should be routine in the initial 



18 Medical News Letter, Vol. 34, No. 7 






examination and subsequent evaluation of patients who have Cushing's syn- 
drome, (T.P. Kearns, et al. , A.M. A. Arch. Ophth. , August 1959) 

Tibial Stress Fractures . Analyzing 35 cases of stress fractures of the tibia 
from the U.S. Naval Hospital, Camp Pendleton, Calif. , the author stresses 
the importance of the lesion in the differential diagnosis between bone tumor, 
osteomyelitis, and thrombophlebitis. The insidious development of symptoms 
combined with delayed x-ray evidence of pathology contribute to possible con- 
fusion in diagnosis of the typical case. (J. Benedict, J. Internat. Coll. Surg- 
eons, August 1959) 

Intravenous Fat Emulsion . The authors studied the effect of an intravenous 
fat emulsion on blood coagulation, observing that hypocoagulability of the 
blood occurred in most patients and severe hemorrhage occurred in 3 of 20 
patients. The condition reverted to normal without treatment other than whole 
blood transfusion which was required in three instances, Hypocoagulability 
may develop from fat emulsion given intravenously when more than 500 ml. 
per day is given for a period longer than 14 successive days. (J. A. Werr, 
F. W. Preston, A.M. A. Arch. Surg., August 1959) 

Carcinoma of the Thyroid . Noting an increase of frequency of carcinoma of 
the thyroid during the past 5 years, the author stresses that surgery should 
be performed on all children with nodular goiter, men with nontoxic nodular 
goiter, and all patients with discrete or solitary tumor. The type and extent 
of operation should be governed by immediate frozen section determination 
of the type of growth present. Radioactive iodine has been of use in locating 
metastases and, to a limited extent, in treatment. (R. Ward, J. Internat. 
Coll. Surgeons, August 1959) 

Deaths from Bites and Stings . Of 215 deaths during 1950 - 1954 due to bites 
and stings of venomous animals, insects (Hymenoptera — bees, wasps, hornets, 
yellow jackets, and ants) killed more (40%) than venomous snakes (33%). 
Rattlesnakes were the most dangerous venomous animals, accounting for 55 
deaths, while bees were next most deadly, taking 52 human lives. 
(H. M. Parrish, A. M. A. Arch. Int. Med., August 1959) 

Vascular Brain Syndromes. In anatomical drawing, tabulation, and diagram, 
schematic representation of the vascular supply of the brain and of the cranial 
nuclei is presented, which is considered an excellent aid in the diagnosis of 
occlusive vascular lesions of the brain and brain stem. (M. Holtzman, et al. , 
Am. J. Phys. Med. .August 1959) 

Gastric Acid Rebound . From review of recent literature and their own studies, 
the authors consider that there is no support for the commonly held assumption 



Medical News Letter, Vol. 34, No. 7 19 



that there is an "acid rebound" phenomenon in response to alkali ingestion. 
(J. Pereira-Lima, M. D. , F. Hollander, Ph. D. , Gastroenterology, August 1959) 

*•&* *>V >iV «Kv J* 
■V "T* "T* <P 'l"" 

BUMED INSTRUCTION 1500. 4B 21 August 1959 

From: Chief, Bureau of Medicine and Surgery 

To: Ships and Stations Having Medical Corps /Dental Corps Personnel 

Sub}: Professional examinations and memberships in civilian professional 
societies for Medical and Dental officers; reporting of 

This instruction informs Medical and Dental officers of the requirement for 
furnishing the Bureau of Medicine and Surgery information relative to pro- 
fessional examinations and memberships in civilian professional societies. 

T* *5* *S* *P *f* *T* 

BUPfiRS INSTRUCTION 1120. 15D 10 September 1959 

From: Chief of Naval Personnel 

Commandant of the Marine Corps 
To: All Ships and Stations 

Subj: Permanent and temporary appointment in the Medical Service Corps, 
Regular Navy; inservice procurement programs for 

This instruction consolidates two prior directives (BuPersInst 1120.8A and 
BuPersInst 1120. 15C) thereby establishing a uniform procedure for the pro- 
cessing of applications from qualified men and women on active duty for 
appointment in the various sections of the Medical Service Corps, U.S. Navy. 

As a result of the warrant officer phase-out program, this directive initiates 
procurement of temporary officers as a replacement for the Medical and 
Dental warrant input. It is emphasized that this replacement concerns initial 
appointments only. It does not mean replacement of existing warrant officers. 
Temporary appointments in the Supply and Administration Section may be 
tendered up to the maximum age of 35 years as of 1 July of the year in which 
the appointment can first be made. 

Commanding Officers are requested to disseminate the content of this instruc- 
tion to insure that all eligible personnel are cognizant of its provisions. 

5ft 5,-. 3fi JjC -Y- ?p 



20 



Medical News Letter, Vol. 34, No. 7 



DENTM 




SECTION 



Message from the Chief of the Dental Division 

"To all Navy Dental Personnel: 

This letter is to express my sincere appreciation to all of you 
who, on August 22, so wholeheartedly supported the commemoration 
of the Forty-Seventh Anniversary of the founding of the U.S. Navy 
Dental Corps. Many excellent reports of your successful affairs have 
reached this Bureau through copies of ships' and stations' publications 
and civilian newspapers. The articles in these publications were 
uniformly in good taste and can result only in enhanced public respect 
for our profession and the Navy. I am confident that the birthday 
celebration contributed significantly to the solidarity and esprit de corps 
of our organization. 

I am happy to report that the ceremonies, receptions, and news 
articles were so numerous this year that it is not practicable to send 
individual letters of appreciation to the heads of dental facilities who 
sponsored commemorative activities. I am pleased that your enthu- 
siastic support in recognizing the anniversary of our Corps has made 
it necessary for me to use an open letter to express to you this 

Well Done - 
1st 
C. W. SCHANTZ" 

;J: % % sjc s[c iff 



Response to Implants of Anorganic Bone 

While initial host acceptance of anorganic bone implants has been 
demonstrated previously, the ultimate fate of these osseous grafts has not 
been observed. A long-term histologic evaluation of anorganic bone im- 
plants in man was undertaken to parallel similar animal studies currently 
being made. . 



Medical News Letter, Vol. 34, No. 7 21 



Implants of anorganic bovine bone were placed in oral bony defects 
of human patients. These defects had resulted from the destruction of alveo- 
lar bone by commonly occurring periapical and periodontal pathologic lesions 
and from loss of osseous structure attending complicated exodontia. The 
postoperative course was uniformly uneventful. 

Biopsies of the implanted defects, from 3 to 18 months postoperatively, 
were obtained in 15 cases. Histologic evaluation of these specimens revealed 
a general lack of significant inflammatory response surrounding the anorganic 
particles. At the periphery of the defects the anorganic particles were being 
remodeled by reactive -appositional bone growth. There was a general lack 
of osteogenic activity around anorganic particles which were not in intimate 
contact with the host bone. Implanted particles lying immediately beneath 
the mucoperiosteum or in the central portion of the defect were, in general, 
surrounded by fibrous connective tissue. In some defects, in which attempts 
had been made to restore alveolar contour and height, the labial and buccal 
cortices had reformed, engulfing anorganic particles in the newly formed 
matrix. However, osteoblastic and osteoclastic activity at the periphery 
of these particles was minimal. Persistence of implanted anorganic par- 
ticles over prolonged periods of time postoperatively and general long-term 
histologic status of the implants would tend to indicate the limitations in the 
clinical use of this material. (P.J. Boyne, Marine Corps Base, California, 
H. W. Lyon, Dental Division, Naval Medical Research. Institute, Bethesda, 
Maryland: Journal of Dental Research, S-15, July - August 1959) 

**JL* *.'* O.- *.'.' '.i.- 
-,- rfm r(H »,- rf*. 

New Correspondence Extension Course 

A correspondence extension course in oral diagnosis {Oral Diagnosis, 
NavPers 10739) is available to officers of the Dental Corps of the U.S. Navy 
and Naval Reserve. The course was developed by the staff of the U.S. Naval 
Dental School, National Naval Medical Center, Bethesda, Md. , with the 
assistance of professional test constructors of the Home-Study Department 
of the University of Chicago. 

Reserve Dental officers may receive promotion and/or retirement 
points to be credited at the completion of course units. The first unit of the 
course, "Oral Diagnosis, " is comprised of assignments 1 through 6 and is 
evaluated at 12 points; the second unit consists of assignments 7 through 10 
and is evaluated at 6 points. These points are creditable only to personnel 
eligible to receive them under current directives governing retirement and/or 
promotion of Naval Reserve personnel. 

This is the third of a group of postgraduate level extension courses 
being prepared under the auspices of the Naval Dental School to augment the 
continuing education program for officers of the Navy Dental Corps. The 



22 Medical News Letter, Vol. 34, No. 7 



courses previously prepared are Prosthodontics, Part II, Partial Denture 
Prosthesis, NavPers 10764 (Medical News Letter, 7 November 1958), and 
Endodontics, NavPers 10407 (announced in Medical News Letter of 3 July 
1959). 

"Oral Diagnosis" is comprised of ten assignments covering the phil- 
osophy of treatment planning, special methods of examination, special diag- 
nosis of dental and oral diseases, and suggested treatment procedures. 

Not specified in the original description of the course, it is announced 
that nine promotion and/or retirement points will be credited to Reserve 
Dental officers completing the extension course in Endodontics (NavPers 
1040 7) which consists of three assignments. 

Applications for enrollment in these courses should be submitted on 
NavPers 992, Application for Enrollment in Officer Correspondence Course, 
via official channels, changing the "To" line to read: Commanding Officer 
{Code 5), U.S. Naval Dental School, National Naval Medical Center, Bethesda 
14, Md. 

•'f "('• ^r> "i~ *r* 'j 1 * 

Newly Standardized Dental Item 

A newly standardized periosteal elevator has been made available 
through regular supply channels. Information pertaining to the new item is: 

Stock Number Item Description Unit Price 

FSN 6250-584-2699 Elevator, Periosteal, $2.90 

Molt, No. 9; double 
ended 

i}i * * * * * 

Technician Training in Maxillofacial Prosthesis 

Applications are desired for training in Maxillofacial Prosthesis. 
Dental Technicians in the rates of DTI and DT2 with a primary Navy Enlisted 
Classification of 8752 and in the third segment of the SEAVEY (October 1959) 
are encouraged to submit requests. Applications must be submitted in accord- 
ance with BuMed Instruction 1510. 2B. Preference will be given to those Dental 
Technicians who have completed 4 years of active naval service. 

****** 



Medical News Letter, Vol. 34, No. 7 23 




RESERVE WM9^ SECTION 



Tables of Organization for Naval Reserve, Fiscal Year I960 
BuPers Instruction 5400. 1H, 1 July 1959 

(Continued from Medical News Letter, 18 September 1959) 

4, Equivalent Duty . Equivalent duty shall be approved and conducted in 
accordance with the instructions contained in Article H-4206 of the BuPers 
Manual. The scheduling of equivalent duty is discretionary with unit com- 
manding officers. Equivalent drills may be performed only in the quarter 
in which the regular drills being made up were missed, except that regular 
drills missed in the final month of any quarter may be made up in the first 
month of the next quarter if circumstances prevent make-up during the 
month in which missed. The maximum number of periods of equivalent 
instruction or duty that may be performed by individual members of the 
various programs are: 

Max. No. Regular 

Drills Authorized Maximum No. of Periods, Authorized Equivalent Duty 

Annually Per Annum Per Quarter Per Month Per Week 

48 8 4 2 2 

36 6 3 2 2 

24 4 2 2 2 

5. Appropriate Duty . 

a. The purpose of appropriate duty is to permit the commandants to 
accomplish certain tasks and functions which are in support of the Naval 
Reserve and the Marine Corps Reserve. In addition, appropriate duty may 
permit commandants to accomplish tasks in support of the Naval Service 
generally, and to authorize special categories of training for individual 
Naval Reservists. 

b. Commandants are authorized to issue appropriate duty orders to 
individuals of the Naval Reserve not on active duty who are qualified to per- 
form the duties required of them by such orders. It is the responsibility 

of the commandant to determine that appropriate duty performed is of sub- 
stantial benefit to the Navy generally, and to exercise close supervision 
over the performance of appropriate duty. 

c. Categories of Appropriate Duty Authorized . 

(1) Appropriate duty orders may be issued for the performance of 
tasks in support of Selected Reserve and Marine Corps Reserve as follows: 



24 Medical News Letter, Vol. 34, No. 7 



(a) To 2105, 2205, and 2905 officers for the performance of 
medical and dental examinations, and essential services of an administra- 
tive nature for Naval Reserve or Marine Corps Reserve units; 

(b) To 3105 officers for assisting Naval Reserve Training 
Centers in the procurement, handling, and issuance of clothing and small 
stores, the preparation of necessary vouchers for disbursing officers and 
in other supply and fiscal matters where such assistance is not available 
through active duty support personnel or inactive duty personnel attached to, 
or associated in pay status with, drilling units supported by the Training 
Center concerned; 

(c) To 4105 officers for assisting Naval Reserve and Marine 
Corps Reserve training activities in providing spiritual, moral, and tem- 
poral welfare support to members of Naval or Marine Corps Reserve units. 
(Chaplains selected for this duty with pay must either have served on active 
duty as chaplain, or have performed 2 weeks active duty for training as 
chaplain and have completed correspondence courses in Navy Regulations 
(NavPers 10704-A, and the Navy Chaplain, NavPers 10905-A).) 

(d) To 5105 officers for the performance of duties similar to 
those performed by an officer of the Civil Engineer Corps assigned to a 
regular Navy activity as Public Works Officer, such duty to be for the bene- 
fit of Naval Reserve Training Centers which are located in areas not readily 
available to staff personnel assigned to the District Public Works Officer. 
(Areas which are outside a 50-mile radius of District Headquarters may be 
considered not readily available.) 

(e) To individual Naval Reservists for acting as the Comman- 
dant's Local Representative to assist drilling unit commanding officers in 
the field of recruiting and procurement. 

(f) To individual Naval Reservists who participate with drilling 
units of Selective Service Programs of other branches of the Armed Forces. 

(2) Appropriate duty orders may be issued for the performance of 
the following tasks in support of the Naval Service generally: 

(a) To 2105 and 2205 officers for duty as consultants at Naval 
Hospitals (Appointment of officers for this duty must be approved by the 
Commanding Officer of the Hospital concerned and by the Chief, Bureau of 
Medicine and Surgery.), and for the conduct of physical and dental examina- 
tions for members of the Naval Reserve. In this latter authorization, the 
completion of three physical examinations or five dental examinations shall 
constitute the basis for one appropriate duty credit. 

(b) To individual Naval Reservists for representing the Com- 
mandant in local areas where he cannot be represented by suitable active 
duty personnel, such representation to include attendance at public cere- 
monies, matters concerned with legal duties, public relations, the admin- 
istration of the Naval Reserve in a local community, recruiting, and pro- 
curing personnel for membership in drilling units. 



Medical News Letter, Vol. 34, No. 7 25 



(3) Appropriate duty orders may be issued for the performance of 
the following special categories of training: 

(a) Attendance at symposiums, or other training or lecture prog- 
rams conducted under the auspices of the Armed Forces.; (Symposiums must 
be sponsored by, and under control of, the military and may be conducted in 
conjunction with professional or trade conventions. In this event, they must 
have received prior approval of the Bureau or Office concerned and the Chief 
of Naval Personnel. ) Credit may be granted only when: 

1. An individual participates in his capacity as a Reservist 
and devotes his time and effort beyond that normally associated with his 
civilian occupation. 

2. Such activity is engaged in without remuneration other than 
pay to which he may be entitled as a member of a Reserve component. 

3. Such activity demonstrably improves the individual's fitness 
to perform the military duties to which he may reasonably be expected to be 
assigned upon mobilization or similarly improves the fitness of others by his 
supervisory responsibilities on such an occasion. 

(b) To individual Naval Reservists for participation in Naval 
Reserve Communication Networks. 

(c) To individual Naval Reservists for participation with drilling 
units of the Selective Service Program. 

d. Pay Status . Pay status may be authorized in orders issued to Ready 
Reserve or Marine Corps Reserve units not to exceed 48 periods per year. 
The number of orders so issued will not exceed the quotas established in 
Table 26. Pay status will not be authorized for other categories of duty. 
Appropriate duty orders without pay may be issued to Ready or Standby 
(Active) Reservists for all purposes listed in paragraph 5. c. 

e. Limitations 

(1) Appropriate duty orders may be issued to members of drilling 
units of all programs only for purposes set forth in paragraph 5. c. (2) and 
(3) (a) and (b) above. 

(2) In the event qualified officers are not available in a given locality 
for the performance of a support task, then fully qualified commissioned 
warrant officers, warrant officers, or enlisted personnel may be issued 
orders. 

(3) Orders issued for the performance of a task in support of the 
Naval Service generally or special categories of training may indicate ter- 
mination of the orders on completion of specific duties or may be on a per- 
manent, continuing basis. 

(4) Credits for any purpose for the performance of appropriate duty 
will not exceed the following numbers of periods: 

Annually ... 48 Monthly. . . 6 
Quarterly . . 13 Weekly ... 2 
Daily 2 



26 Medical News Letter, V ..' •'.. No. 7 



If two periods of appropriate duty are performed in one ti^y, then each 
period will consist of duty of not less than 4 hours' duration. 

f. Reports of Performance of Duty . Individuals under appropriate duty 
with pay orders will report and certify their performance of such duty month- 
ly in letter form to the Commandant concerned, via the Commanding Officer 
or Officer in Charge of the military activity, if any, to which the Reservist 
has been directed to report. Individuals under appropriate duty without pay 
orders will make a similar report and certification quarterly to the Com- 
mandant. However, the attendance of personnel attending approved sym- 
posiums or other training or lecture programs may be reported in composite 
letter form directly to the Officer in Charge, Reserve Officers Recording 
Activity with copies to the Chief of Naval Personnel and Commandant concerned. 

g„ Content of Orders . In addition to the requirements of the BuPers Manual, 
Article H-4207 (2) (a), appropriate duty orders will stipulate: 

(1) That the orders are subject to the consent of the Reservist concerned; 

(2) That acceptance of the orders by performance of duty under them 
subjects the Reservist to the Provisions of the Uniform Code of Military Justice; 

(3) The military command, if any, to which the Reservist will report in 
compliance with the orders. 

NOTE: Additional excerpts from this important Instruction will be published 
in succeeding issues of the Medical News Letter. 

jfc *Bj j&j jfc jfe sfe 

Comments We Like to Read 

The following letter from a member of the Navy's Ensign Medical 
Program was written to LCDR Matthias H. Backer, Jr. , MC USNR, Com- 
mandant's Representative and member of the faculty of St. Louis University 
School of Medicine. The writer, ENS Fred C. Leisse 1915 USNR, a fourth- 
year medical student at the above University, is currently enrolled in the 
Navy's Senior Medical Student Program and participated in last summer's 
NROTC Midshipmen Cruises. His comments concerning his experiences 
at sea are considered worthy of reprint and are published here with the per- 
mission of the writer. 

July 17, 1959 
"Dear Dr. Backer - 

I want to thank you for everything you did in helping me get this 
cruise. It has been wonderful. I've seen the real Navy, and I like it. 
I have had experiences which I may never realize again, and they have 
been great. I have been thrown into the company of men who are some 



Medical News Letter, Vol. 34, No. 7 27 



of the finest I've ever met. I've been accepted as an equal by men who art 
without a doubt the backbone of this country, and a strong backbone it is. 

At present I am aboard the destroyer U. S.S. DAMATO, spending a 
few days to see what the practice of medicine is like aboard a small ship. 
Until yesterday the U. S.S. RANDOLPH was my ship. It is one of the 
largest carriers, angle deck and all. I was high-lined over here during 
refueling, which was quite an experience, I also had the thrill of being 
catapulted off the carrier in one of the anti-sub planes, got to fly it for 
about half an hour, and then landed again on the flight deck. The catapult 
shot was really something. 

We had 6 days liberty in New York over the 4th. My girl was waiting 
for me on the pier and we had a wonderful time together. Right now we 
are off the coast of Newfoundland, and will arrive in Quebec on July 20 
for a week's liberty. 

I've seen every phase of these ships in operation, and if my movies 
turn out well, we should really have some propaganda material for next 
year. Keep your fingers crossed. 

I hope to return to the carrier Sunday by helicopter so that I can get 
ready for Quebec where everything indicates that we'll get the red carpet 
treatment. I want to thank you again for everything, and though this 
letter is short, I hope you realize how long I am on appreciation for all 
you've done for me. 

I hope you and your family are well. I'll see you back in old St. Louis. 
Until then, I am 

Sincerely yours, 

/•/ 

RICK LEISSE" 

2,^ *p. a-p*. 7jC ? t C 35? 

Change of Address 

Please forw rd requests for change of address for the News Letter to: 
Commanding Officer, U.S. Naval Medical School, National Naval Medical 
Center, Bethesda 1 1 Md. , giving full name, rank, corps, and old and new 
addresses. 

.,. *,c Vf jjt ;,» 5^ 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget, 19 June 1958. 

Ht * * ^c %: sic 



28 Medical News Letter, Vol. 34, No. 7 




OCCUPATIONAL MEDICINE 



Occupational Health Congress in New York 

The 13th International Congress on Occupational Health will be held 
25 - 29 July I960 in the Hotel Waldorf-Astoria, New York City. It is being 
organized under the auspices of the International Association on Occupational 
Health. The program will include physicians, nurses, and industrial hygien- 
ists representing more than 40 countries. The following phases on occupation- 
al health will be considered: administrative methods, medical and surgical 
practices, education and training, social and legal aspects, work physiology 
and psychology, environmental factors in health, environmental hygiene, and 
hazards of specific industries. 

Naval Medical officers engaged in the practice of Occupational Med- 
icine and Naval Industrial hygienists, both military and civilian, are strongly 
urged to present papers in their respective fields of endeavor at this Congress, 

Information may be obtained from Dr. Irving R. Tabershaw, Chairman, 
Scientific Program Committee, International Congress on Occupational Health, 
375 Park Ave. , New York City. 

^p- *|* 3p ?|C *f% w^ 

Radiation as an Industrial Medical Problem 

Radiation was an industrial health problem long before nuclear reac- 
tors and atomic bombs became a reality. Therefore, it is not exactly accurate 
to equate the coming of atomic energy with the introduction of radiation as an 
industrial health problem. It is true that only with the successful development 
of the nuclear reactor did available sources' of radioactivity cease to be a few 
curies and grow quickly to millions of curies. This is the reason why the 
radiation hazards of the nuclear age are potentially greater by orders of mag- 
nitude than in prior years and why Dr, Detlev W. Bronk, in his foreword to 
the 1956 NAS-NRC Summary Report, "The Biological Hazards of Atomic 
Radiation, " was justified in saying: 



Medical News Letter, Vol. 34, No. 7 29 



"The use of atomic energy is perhaps one of the few major tech- 
nological developments of the past 50 years in which careful consideration 
of the relationship of a new technology to the needs and welfare of human 
beings has kept pace with its development. Almost from the very begin- 
ning of the days of the Manhattan Project careful attention has been given 
to the biological and medical aspects of the subject. By contrast, the 
automobile revolutionized our pattern of living and working, but we are 
only now beginning to appreciate the problems of safety, urban congestion, 
nervous tension, and atmospheric pollution which have accompanied its 
development. " 

The most characteristic feature of radiation as a day-to-day indus- 
trial health problem is the long latent period which elapses between exposure 
or beginning exposure and the first appearance of clinical or laboratory evi- 
dence of injury. In general, the lower the exposure or exposure rate the 
later resulting injury manifests itself. Usually, years intervene before 
malignant change appears. Any genetic effects would appear in succeeding 
generations and probably be demonstrable only on a statistical basis. Acute 
injuries have occurred and will be a continuing threat so long as nuclear 
energy continues to be exploited for the benefit of society or as a weapon of 
war. Industrial physicians must learn how to deal with such eventualities, 
but in their day-to-day contact with radiation problems they will be concerned 
principally with prevention of over-exposure to radiation and care of the less 
dramatic injuries Involving radiation, such as localized skin burns and wounds 
contaminated with radioactive materials. 

First knowledge of the carcinogenic action of radiation exposure was 
acquired in 1902, only 7 years after x-rays were discovered. Ionizing rad- 
iations in very large total doses, probably of the order of several thousand 
roentgens to the skin, were observed to have caused skin cancer. During 
the next two decades cases of radiation-induced skin cancer among physicists 
and radiologists appeared and were related to exposures incurred during their 
work as scientists, but it was not until the middle 20' s that radiation was 
clearly established as an industrial health hazard in the usual sense of the 
word. 

In 1935 Martland reported an outbreak of cases of osteitis, anemia, 
and bone cancer in young women, all employed in the watch dial industry. 
This study has become a classic in what might be called radioepidemiology. 
Meanwhile, it was known that in Czechoslovakia in pitchblende mines which 
had been worked for centuries for a variety of minerals, death from pulmon- 
ary disease was the rule. By 1913 it was established that a prime cause of 
death in these workers was lung cancer, and in 1942 it was established that 
the atmosphere of the mines contained considerable concentrations of radon 
gas, probably great enough to be the causative agent for the lung cancers. 

In 192 7 Muller established that roentgen irradiation of germ cells of 
the fruit fly resulted in gene mutations. In the 1930 's it was established 



30 Medical News Letter, Vol. 34, No. 7 



that whole -body irradiation in single or divided doses was leukemogenic in 
mice. By 1940, except for the effects of whole-body radiation exposure on 
average life span, the general nature of hazards inherent in working with 
radiation and radiation sources was known although poorly quantitated. 

Beginning in 1929 a group which later became the National Committee 
on Radiation Protection and Measurement began cooperating with the Inter- 
national Commission on Radiological Protection in developing recommenda- 
tions concerning the maximum permissible exposure of the relatively few 
adult workers who were then using x-ray machines and radium and, later, 
other sources of ionizing radiation. In 1950 the recommendation was 0. 3 r 
per week or 15 r per year, and in 1957 the average annual permissible 
exposure was set at 5 r. (The present average permissible exposure allows 
0. 3 r/week, but not more than 3 r/quarter and not more than an average of 
5 r/year. ) 

It is interesting to see how the picture looked at the time to those 
responsible for the health of the workers on the atomic bomb project: 

Early in 1942 scientists of the Metallurgical Laboratory became con- 
vinced that a nuclear chain -reacting pile could be built. They realized 
the enormity of the health hazards that such a unit would create. Some of 
them had friends or acquaintances who had been injured in experimental 
work with x-rays or with radium, and many were aware of the harmful 
effects suffered by some workers in the radium-dial industry. 

Since no one person could have all the required knowledge or could 
know how to acquire it, a health group was formed which gradually evolved 
into an organized Health Division. The objectives of the Health Division 
as stated by the Laboratory Director were: 

1. Protection of the health of the workers on the project. 

2. Protection of the public from hazards arising from the operation 
of the project. 

3. A study of the peculiar hazards for the purpose of being better 
able to establish tolerance doses, to predict more accurately what might 
happen in the future, to devise means of detecting ill effects to personnel, 
and to discover methods of treating any person who might be injured, 

A broadly conceived research program was initiated to study the bio- 
logic effects of ionizing radiation. This program drew on the talents of 
many university scientists and scientists in the government, notably from 
the National Cancer Institute and the National Bureau of Standards. The 
syndrome of whole -body radiation injury was clearly defined before it was 
observed in Japan in 1945, and experimental studies were initiated in mice 
on genetic effects of radiation, effects of radiation on life span, and car- 
cinogenic action of internally deposited radioactive materials. The actual 
scope of health service activities by spring of 1944 was summarized 
as follows: 



Medical News Letter, Vol. 34, No. 7 31 



1. Surveys of skin for contamination with radioactive materials. 

2. Surveys of laboratories for various types of radioactive contam- 
inants. 

3. Metering of personnel with various types of pocket ionization 
chambers and film meters to determine individual exposures. 

4. Surveys of atmosphere for radioactivity. 

5. Surveys of effluent water from the Clinton pile area to determine 
contamination. Methods developed here expected to be useful at Hanford. 

6. Examinations of body secretions and excretions for radioactive 
materials. 

7. Clinical laboratory examinations for various types of damages to 
personnel exposed to either tolerance or larger doses or radiation. 

This statement still applies as a guide to those responsible for the 
health of workers and the public in an industrial plant handling radioactive 
materials. 

In June 1956 the National Academy of Sciences and the British Medical 
Research Council published reports on the biologic effects of radiation. 
These reports were stimulated by concern over possible harmful effects of 
radiation from fallout from testing of atomic weapons. Both reports con- 
cluded that any radiation exposure might exact a biologic cost at least from 
the genetic standpoint. The reports further suggested that, except for expos- 
ure from natural radioactivity, medical x-rays were the largest single factor 
in exposure to the population as a whole. This has led to active efforts to 
reduce body and gonadal exposures from diagnostic and therapeutic x-rays. 
Each industrial medicine program in a plant which uses radiation sources of 
any type, even if it includes only the diagnostic x-ray machine in the plant 
medical office, must be cognizant of radiation as an industrial health prob- 
lem. It behooves each industrial physician to become conversant with rad- 
iation medicine, treatment of radiation accidents, and methods of controlling 
radiation exposures generally, as well as to gain a more detailed knowledge 
concerning the particular radiation sources being used in the plant or plants 
for which he has medical responsibility. 

There are too many variations in the amount and kinds of radioactive 
material handled for any set rules to be established. Each plant will have 
its own special problems. In many instances, the major share of the res- 
ponsibility for radiation health protection is placed on the man most com- 
petent to bear it, whether a physician, a radiological or health physicist, 
or an industrial hygiene engineer. The important thing is that the respon- 
sibility is clearly assigned to someone who understands radiation protection 
problems. The medical director must keep close contact with the program, 
even if he does not administer it. He must have full under standing of the types 
of accidents which could arise and be prepared to handle radiation injuries 
quickly and competently. 



32 Medical News Letter, Vol. 34, No. 7 



Education of personnel is a further responsibility which the physician 
or medical director must undertake. There is so much talk of hazards of 
radiation that lay persons frequently become unnecessarily apprehensive 
about them. Considerable numbers of persons are refusing to submit to 
important diagnostic x-ray procedures because of something they have read 
or heard on the radio or television. The worker first turns for guidance to 
the industrial physician and the family physician who must be prepared to 
discuss the problem with him in simple understandable terms. The American 
College of Radiology has developed a useful pamphlet which should be read by 
every industrial physician. It can do much to place the hazards inherent in 
diagnostic x-ray exposure in proper perspective. 

For a number of years the Industrial Medical Association and the 
American Industrial Hygiene Association have devoted whole sessions at 
annual meetings to the health problems of the atomic age. Industrial phys- 
icians should take advantage of every opportunity to learn about radiation 
hazards, methods for their control, and therapy of injuries incurred in acci- 
dents involving radiation and radioactive materials. (Dunham, CM. , Rad- 
iation as an Industrial Medical Problem: J. Occup. M. , 1: 199-202, April 1959) 



Etiology of Aplastic Anemia 

Aplastic anemia is not commonly associated with exposure to indus- 
trial chemicals, particularly under conditions prevalent in modern chem- 
ical plants. Early in the century, aplastic anemia was frequently noted 
following over-exposure to benzene, particularly in Germany, England, and 
Italy. The first cases of chronic benzene poisoning were recorded in 1897. 
Since that time, two other compounds — dinitrophenol and trinitrotoluene — 
have been implicated, and more recently, a mixture of DDT (dichlordiphenyl- 
trichloroethane) , chlordane (octachloro — 4,7= methanohydroindane), and 
lindane (benzene hexachloride) is reported to have caused aplastic anemia 
in a 16 -year old boy. A single report of aplastic anemia due to carbon 
tetrachloride has been criticised for lack of proof of coincident exposure 
to other solvents such as benzene. 

Wintrobe lists 25 drugs associated with the occurrence of aplastic 
anemia, and Osgood lists 25 agents known to produce hypoplastic syndromes 
of drug idiosyncrasy type. Of these agents, only nitrophenols are of indus- 
trial significance. Osgood prefers the term hypoplasia rather than aplasia 
because complete disappearance of cells from blood-forming organs prac- 
tically never occurs because erythrocytic, granulocytic, and thrombocytic 
hypoplasia may occur separately or together. He points out that before 
attributing aplasia or aplastic anemia to drugs or chemicals it is necessary 
to keep in mind other causes of hypoplasia, such as bacterial, viral, or 



Medical News Letter, Vol. 34, No. 7 33 



parasitic infections, nutritional and endocrine deficiencies, endogenous 
toxins, congestive splenomegalies, thymomas, and other more rare and 
obscure causes of hypoplasia. 

A comparison of deaths and illness from trinitrotoluene during World 
War I and World War II indicates the effectiveness of control measures intro- 
duced during the second World War. McConnell and Flinn summarized the 
findings in 22 fatalities occurring in the United States during World War II 
between June 1941 and September 1945 — sharp contrast to the 475 deaths 
during the first 7-1/2 months of World War I, 

In the chemical industry every effort is being made to eliminate or 
reduce exposure to toxic chemicals to a safe level. The possibility of expos- 
ure to TNT is much less in a manufacturing plant than in a shell-loading 
plant because in the latter TNT must be melted and there is more chance of 
inhaling fumes and dust or absorbing the compound through the skin. The 
The DuPont Company operated four TNT -manufacturing plants employing 
some 4000 persons during World War II, producing about 1-1/4 billion pounds 
of this explosive. By maintaining rigid standards with respect to permissible 
levels of TNT in the air, enforced showers after work, and the daily use of 
freshly laundered clothing, gloves, and caps, exposure was reduced so that 
no cases of toxic hepatitis or anemia developed in the 4-year period these 
plants were in operation. 

There may be several reasons why therapeutic chemicals are more 
often associated etiologically with aplastic anemia than industrial chemicals. 
A drug is given in an effective dose which is some optimal level between the 
smallest amount having a therapeutic effect and the largest amount that can 
be tolerated without toxic symptoms. In the chemical industry, to avoid 
having any person subjected to even a minimal dose (a dose or exposure 
which produces any measurable effect) the concentration of gas, vapor, or 
dust in the atmosphere is kept well below permissible limits and protection 
against skin contact is provided. In this way, even the most toxic compounds 
can be manufactured and handled safely. 

During the past two decades manufacturing chemists have made a 
concerted effort to determine in advance the possible hazards of new chem- 
icals or products with respect to their effect on the skin, or following absorp- 
tion into the body by any route, so that safety standards can be established. 

Many chemical industries have a full-time in-plant medical service. 
Through preplacement examinations the state of the employee's health is 
known and must meet certain standards before he is permitted to enter an 
operation involving chemicals that may be toxic. The employee is examined 
periodically to be sure abnormal signs or symptoms are not present. The 
frequency of examination depends on the job and the possible hazards involved. 
Thus, a correlation between medical observations of the worker and measure- 
ments of the environment in which he works is possible. Individual variations 
are assessed and compared with variations in the group. Often, factors 



34 Medical News Letter, Vol. 34, No. 7 



outside the industrial plant are found to be responsible for individual varia- 
tion. One of these factors is the large number of chemicals used therapeutic- 
ally, and the number of these substances is expanding rapidly. 

In 195 7 seventeen million pounds of aspirin were manufactured, enough 
to make 23 billion 5 -grain tablets. Vitamins came second on the list, to the 
extent of some 7 million pounds. Little or no medical guidance prevails in 
the use of these drugs. Instead, the public is deluged with information con- 
cerning wonder cures for a variety of symptoms. 

Perhaps the introduction to so many new synthetic drugs represents 
progress, but at times it is disconcerting to those who are responsible for 
preventing injury from chemicals used in industry. Medical textbooks 
rightly suggest that exposure to industrial chemicals should be considered 
in etiology of diseases like aplastic anemia, but the odds are about 12 to 1 
in favor of therapeutic agents being responsible. 

Time limitations make it difficult in industry to obtain a detailed or 
reliable history of past exposure to drugs or chemicals at the time of a 
preplacement examination. Usually it is possible to obtain a history of 
impressive reactions, particularly skin reactions, to chemicals or drugs. 
The prospective employee may recall these unless he assumes it may inter- 
fere with his chance of employment. It is feasible, however, to establish 
that workers assigned in a specific area are of normal health or at least 
measure up to certain standards before being employed in a chemical opera- 
tion. A normal blood picture would be one of these standards. Osgood, in 
discussing drug-induced hypoplastic anemias and related syndromes, points 
out the usefulness of the reticulocyte count to determine early unfavorable 
reactions to drugs, since a reduction in reticulocytes, neutrophils, or 
thrombocytes in the blood will long precede the development of anemia 
because of the long life span (120 days) of mature erythrocytes. He suggests 
that, owing to the difficulty in doing reliable thrombocyte counts, a clot- 
retraction test be performed. This procedure would be feasible in some 
selected industrial operations as a measure of normal thrombocytic activity. 
Such tests as bone marrow aspirations are not within the scope of industrial 
medicine. Any diagnostic test used in industry must not be too time consum- 
ing, painful, or obnoxious to the employee, and it must measure changes or 
trends in physiology rather than pathology if it is to serve any useful purpose 
in the prevention of poisoning or undue reactions from chemicals. In a per- 
iodic examination of the blood for controlling exposure to a chemical, the 
most likely indications of adverse effect of a chemical on the blood would 
be a reduction in reticulocytes, a reduction of the absolute number of lympho- 
cytes, or a reduction in thrombocytes as measured by delayed or incomplete 
clot retraction. Although the reason might not be apparent, an employee 
exhibiting these changes may be removed at least temporarily from exposure 
until the reason for deviation from normal is established. 



Medical News Letter, Vol. 34, No. 7 35 



The probability of developing hypoplastic anemia from occupational 
exposure to chemicals is much less than from exposure to chemicals used 
therapeutically. The chief reason for this is inherent in the relative risk. 
In industry, the level of chemical exposure is normally kept below a level 
that would produce any effect in any worker. On the other hand, the level of 
chemical exposure during therapy is deliberately high enough to produce a 
desired response even though risk of undesirable side effects is appreciable. 
(Fleming, A.J. , The Etiology of Aplastic Anemia - Industrial Chemicals 
Versus Therapeutic Chemicals: J, Occup. M. , 1: 97-99, February 1959) 

■Jj> J* -j j •■'' ■*'.* -.'■» 

*|* ^fi ■'p ^p *-p *p 

Medical Considerations of Exposure 

to Microwaves (Radar ) 

Considerable interest in the biologic aspects of exposure to radar 
beams has been generated during the past year by widespread publicity of an 
alleged case of human death occurring after brief exposure to an unknown 
quantum of microwaves. The incident served to direct attention to this rel- 
atively new agent, and questions naturally arose concerning the extent of the 
hazard, if any, to persons working with radar transmitters and to those who 
might be exposed in some manner to the energized beam. 

It is not generally known that apprehension over the biologic poten- 
tials of microwaves dates back to the early days of World War II, when Daily 
performed his original studies on U.S. Navy personnel engaged in the opera- 
tion and testing of relatively low-powered radars. Although this study re- 
vealed no evidence of radar -induced pathology in human beings, numerous 
reports have since appeared indicating that tissue injury and animal death 
can occur under certain experimental conditions. These studies indicate 
that cataracts, corneal opacities, testicular degeneration, and hemorrhagic 
phenomena have been induced in anesthetized, small, furry, test animals by 
exposure to microwaves in the frequency range of 2800 to 9000 megacycles 
for various time exposures. Boysen, using a transmitter with a frequency of 
300 megacylces, exposed rabbits in a wave guide and produced damage to the 
central nervous system, degenerative changes in the kidneys, heart, liver, 
and gastrointestinal tract, and hemorrhagic changes in the respiratory tree. 
The power density measured in the wave guide was in excess of 0. 1 watts per 
square centimeter. The animals were exposed for periods of 7 to 10 minutes, 
and all whose rectal temperatures exceeded 44. 5°C. (112. 1 F. ) died. Boysen 
was of the opinion that pathology and death were causally related to the hyper- 
thermia. 

Because of these findings and the apprehension engendered by their 
publication in scientific journals, the medical department of an airframe 



36 Medical News Letter, Vol. 34, No. 7 



manufacturer coincidentally installing, testing, and servicing the most 
powerful airborne transmitters, early in 1954, instituted a comprehensive 
medical surveillance program for its several hundred employees working with 
radar or those who might be exposed to the energized beam. This program 
constitutes one of the longest continuous medical surveys of radar-exposed 
personnel in the United States. 

The objectives of the program were threefold: (1) to detect any cum- 
ulative biologic effects of long-time exposure to microwaves of varying 
frequency and power output in persons who had taken minimal precautions; 
(Z) to observe possible effects on persons working for short periods with or 
near extremely highpowered airborne radar with pulsed wave emissions; and 
{3) to establish correlation between objective findings and units of exposure 
expressed in time -powered density factors with the highly idealized objective 
of establishing safe maximum exposure standards. 

Effects of Long Periods of Exposure 

The initial study included 226 radar-exposed employees and 88 non- 
exposed control subjects. Examination in every case included an extensive 
system and organ inventory with emphasis on the ocular structures, central 
nervous system, gastrointestinal and urinary tracts, hematopoietic system, 
and skin. Imbedded metallic foreign bodies were identified; a careful marital 
and fertility history was elicited; and duration and manner of exposure to radar 
was identified. 

In addition, each subject was inspected for manifest hemorrhagic 
phenomena. A modified test for Rumpel-Leede phenomenon was then per- 
formed by means of placing the blood pressure cuff on the arm and maintain- 
ing pressure midway between the systolic and diastolic pressure for three 
minutes. The appearance of more than 10 fresh petechiae in a circle 4 cm. 
in diameter below the cuff was considered a positive result. 

The second phase consisted of an ocular examination, including a slit 
lamp study performed with the patient subjected to cycloplegia by a compe- 
tent ophthalmologist, complete blood cell and platelet counts, chest x-rays, 
and urinalyses. 

No pathology or adverse physiologic effects unequivocally attributable 
to microwave exposure could be demonstrated, and no person sustained any 
acute or chronic injury secondary to radar exposure. 

Effects of Short Periods of Exposure 

Having established baseline or reference criteria, personnel were 
reexamined, at 6-month, then 12-month, and 24-month intervals approxi- 
mately 4 years after the original study. The procedures were modified to 
eliminate several more costly, time-consuming, and noncontributory tests. 
An extensive medical questionnaire was prepared, and each subject was inter- 
viewed by a physician* Physical examinations were performed only when 



Medical News Letter, Vol. 34, No. 7 37 



indicated on the basis of the medical history or laboratory studies. Ocular 
and slit lamp studies were repeated, and complete blood cell counts and 
urinalyses were performed. Blood platelet studies were repeated on alter- 
nate years. A limited number of electrophoretic serum protein patterns 
were made. 

The number of days of sick leave and leaves of absence and other 
health statistics were obtained. Also, a large number of tests for Rumpel- 
Leede phenomenon were performed on applicants for employment and em- 
ployees seeking treatment for routine ailments. None of these subjects had 
had any known exposure to radar emanations. 

The total exposure group increased to 335 by the addition of newly 
hired or reclassified employees. Persons in the one-year study generally 
had two examinations, in the 2 -year study two or three examinations, and 
in the 4 -year study three or four examinations. 

Among the radar -exposed group, sinus, gastrointestinal, genitourinary, 
and dermatological complaints were most prevalent. Headaches and nervous- 
ness were the most common subjective complaints. The control group exhib- 
ited sinus, allergic, gastrointestinal, joint, and genitourinary disease prev- 
alence, with fewer headaches and skin and respiratory complaints. There 
were no marked deviations or trends from the common disorders and no 
unusual or unexplained hemorrhagic phenomena. 

No ocular finding was attributable to radar exposure. There were 
no cataracts characteristic of those experimentally induced in animals by 
hyperthermia, and the corneal scars were mainly associated with the other 
known causative agents. There were no tendencies toward progressive 
ocular diseases, and the 4-year group revealed no pathology significantly 
different from that of the other groups. 

Sick leave for the 49 subjects who were in the 4-year group averaged 
3. days for the year 1957 compared to 3. 1 days for all factory personnel. 

The blood picture of the radar -exposed and control groups was com- 
parable in most respects. An unusually high incidence of increased mono- 
cytes and eosinophils was noted. Of the 49 subjects studied over 4 years, 
only one had a reduced blood platelet count. Of the 88 subjects used in the 
original control group, positive results were noted in 8%. 

In 26 cases selected at random, electrophoresis of serum proteins 
was performed at a hospital laboratory. Many of these specimens were from 
subjects in the 2-year and 4-year groups. In only one subject was the devia- 
tion more than slight or considered significant, and this was partially re- 
versed within 2 months after elimination of an active known infection. 

Maximum Exposure Standards 

The delineation of safe maximum exposure standards was contingent 
upon detection of pathologic changes in the subjects and determination of the 
exposure parameters with respect to frequency or wave length, field power 



38 Medical News Letter, Vol. 34, No. 7 



density, exposure time, and total test environment. It soon became apparent 
that this objective could not be achieved in the study because no pathology 
caused by either single or repeated exposure was uncovered. The majority 
of personnel had been exposed to radars from transmitters operating in a 
frequency range of 400 to 9000 megacylces including powerful "S" band com- 
ponents. It was impossible to obtain precise data covering exposure time 
and average field power density because often these were unknown. Exposure 
varied from an occasional incidental contact with the beam to as much as 4 
hours daily close exposure periods up to 4 years. Exposures of several 
minutes a day at distances of less than 10 feet from the radars were not un- 
common. 

Protective clothing was not worn by any of the subjects while in the 
radar beam. Personnel were advised to avoid exposure to any firing beam 
when in a zone defined by a minimum power density of 0. 0131 watts per 
square centimeter. A second zone, extending from the area previously de- 
fined to that with a minimum power density of 0. 0039 watts per square cen- 
timeter, was deemed acceptable for occasional pass -through but no constant 
exposure. The third was a limitless zone in which exposure was not deemed 
biologically significant. 

Unfortunately, because most persons are exposed to radar emanations 
while on the ground and frequently within the so-called near radar field, it is 
extremely difficult to evaluate biologic effects and hazards in relation to 
absolute power levels without accurate measurements. The need for such 
accuracy in quantitative determinations of exposure is obvious and can be 
achieved by the development of exposure meters reflecting absorption in 
quantum units of radar energy. 

It has been suggested that the sensation of heat is almost universal on 
exposure to radar and that this in itself is indicative of an overexposure. In 
this study, only 17% of the 335 subjects experienced heat sensation and fre- 
quently only when in close proximity to "X" band radars. Almost 6% were 
aware of a buzzing or pulsating sensation when in an"S" band field. Less 
than 1% experienced other sensations or warning phenomena, such as spark- 
ing between dental fillings or a peculiar metallic taste. Eight subjects gave 
a history of metallic implants, such as bullets, buckshot, steel pins, and 
plates. None experienced any unusual reaction attributable to the metal. 
There were no complaints of heat directed to rings, wrist watches, or 
bracelets. 

Comment 

During the past 18 years, thousands of persons in the course of their 
employment or while in military service have been exposed to microwaves, 
many without protection. Concern over the effects of such exposure is 
natural and to be expected. The majority of radars in common use today are 
relatively low powered with the exception of some military transmitters which 



Medical News Letter, Vol. 34, No. 7 39 



exceed one megawatt in peak power output. Radars with many times this 
power will be operational in due course and may radically change the entire 
concept of the biologic potentials of this form of energy. 

Experiments have been conducted primarily on small fur-bearing 
animals and under unusual test conditions. It is generally accepted that the 
modus of injury by microwaves is a hyperthermia produced by absorption of 
this form of energy by the body. Extreme caution must be exercised in 
attempting to extrapolate the results of small animal responses to heat to 
those of the human body. Small fur -bearing animals have a high coefficient 
of heat absorption, a small body surface, and a relatively poor heat regulating 
system. The human body, by comparison, has an excellent heat regulating 
system and can readily adjust and maintain thermal homeostasis under severe 
stress conditions. Adequate physiologic function can be maintained in environ- 
ments of 240° F. for 23 minutes if the humidity is low; at least one subject 
has been exposed to a temperature of 400° F. for approximately one minute 
without tissue injury. 

Conditions of radar operation and testing vary from experimental con- 
ditions. Human beings are generally exposed while in free air and rarely to 
a stationary energized beam. Some radar beams are extremely narrow, and 
only a small portion of the human body is instantaneously exposed. The body 
can dissipate heat readily to the environment between such exposures. One 
is reminded of a similar problem associated with exposure of personnel to 
the thermal effects of ultrasonic energy. In an analogous situation, small 
fur -bearing animals were destroyed by hyperthermia when placed in a jet 
engine noise field, yet there is no evidence of any adverse heating effects 
on man when exposed to the same environment. It has been estimated that 
it would require many million times the ultrasonic energy of that generated 
by any current jet engine to produce these effects in human beings. 

A case is recorded of accidental 15-second exposure at a 6 to 10 -inch 
distance to ah "X" band radar of over 100, 000 watts in peak power output, 
with resultant erythema and a sensation of warmth for an hour, but with full 
and uneventful recovery. Unless carefully controlled and operated, micro- 
wave diathermy with use of "S" band frequencies can cause local tissue damage. 

The study revealed no acute, transient, or cumulative physiologic or 
pathologic changes in subjects working with, and frequently exposed to, high- 
power radar transmitters. Therefore, it would appear extremely unlikely 
that there exists a biologic hazard to the radar technician observing reason- 
able precautions or that the general public, exposed to greatly attenuated 
and intermittent doses of microwaves in the environment, is in any danger of 
body injury. 

There is need for additional research to explore the effects on living 
tissue of extended wave lengths and frequencies of microwaves and trans- 
mitters of higher energy. 



40 



Medical News Letter, Vol. 34, No. 7 



With the increasing exposure to microwaves in and around the home 
as well as in industry, careless and scientifically uncorroborated report 
of human injury and death cannot avoid receiving dramatic and widespread 
dissemination. If radar is incriminated, the report must contain a definite 
history of exposure, including proper identification of the transmitter, wave 
length, power density, exposure time, symptomatology, laboratory data, 
pathologic findings, and other factors. (Barron, C. L , Baraff, A. A. , 
Medical Considerations of Exposure to Microwaves (Radar): J. A.M. A. , 
168: 1194-1199, November 1, 1958) 






OlVd S33d QNY 30ViS0d 



8*01 "ON liurjed 
SS3NISHH 1VIDIJJ0 

cmviAavw 'n vassmaa 

U31N3D -IVDIC13W 1VAVN 1VNOU.VN 
100HDS 1VDICJ3W 1VAVN 'S 'fl 

AAVN 3 HI dO lN3WIHVd3(3